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Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Importance Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law’s impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Main Outcomes and Measures Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states. (Author abstract)

This brief presents information on work requirement policies implemented by public housing agencies and estimates the percent of households affected by the requirements. Noting the lack of evidence on the outcomes and effects of work requirements on households’ employment and income and on the agencies’ implementation costs, it closes with questions to guide future research and policy considerations. (Author abstract)

This brief presents information on work requirement policies implemented by public housing agencies and estimates the percent of households affected by the requirements. Noting the lack of evidence on the outcomes and effects of work requirements on households’ employment and income and on the agencies’ implementation costs, it closes with questions to guide future research and policy considerations. (Author abstract)

This study examined the relationship between parental substance misuse and child welfare caseloads, which began rising in 2012 after more than a decade of decline. We examined county level variation in both phenomena and qualitative interviews documented the perspectives and experiences of local professionals in the child welfare agency, substance use disorder treatment programs, family courts, and other community partners in 11 communities across the country. Results describe how the child welfare system interacts with community partners to serve an increasing population of parents whose substance use has impaired their parenting and placed their children at risk. (Author abstract)

This study examined the relationship between parental substance misuse and child welfare caseloads, which began rising in 2012 after more than a decade of decline. We examined county level variation in both phenomena and qualitative interviews documented the perspectives and experiences of local professionals in the child welfare agency, substance use disorder treatment programs, family courts, and other community partners in 11 communities across the country. Results describe how the child welfare system interacts with community partners to serve an increasing population of parents whose substance use has impaired their parenting and placed their children at risk. (Author abstract)

Child care subsidies are critical for the well-being of low-income families, including parents’ economic success and children’s development. To inform state efforts to simplify access to child care subsidies and improve service delivery, this report highlights steps taken and lessons learned by five states that participated in the Work Support Strategies initiative between 2012 and 2015. These states worked to improve child care subsidy access and retention, efficiency of service delivery, quality of client service, and alignment with other benefit programs. The report also discusses the implications of these findings for implementation of the reauthorized Child Care and Development Fund. (Author abstract)

Child care subsidies are critical for the well-being of low-income families, including parents’ economic success and children’s development. To inform state efforts to simplify access to child care subsidies and improve service delivery, this report highlights steps taken and lessons learned by five states that participated in the Work Support Strategies initiative between 2012 and 2015. These states worked to improve child care subsidy access and retention, efficiency of service delivery, quality of client service, and alignment with other benefit programs. The report also discusses the implications of these findings for implementation of the reauthorized Child Care and Development Fund. (Author abstract)

Research demonstrates the correlation between childhood adversities linked to poverty and negative outcomes in adulthood, indicating that poverty may itself be considered an adverse childhood experience. Because child poverty is a result of family economic circumstance, policy investments promoting family financial health are imperative to protect child well-being and North Carolina's future prosperity. (Author abstract)

Research demonstrates the correlation between childhood adversities linked to poverty and negative outcomes in adulthood, indicating that poverty may itself be considered an adverse childhood experience. Because child poverty is a result of family economic circumstance, policy investments promoting family financial health are imperative to protect child well-being and North Carolina's future prosperity. (Author abstract)